New Client Registration Form
Thank you for giving us the opportunity to care for your pet. Please take the time to fill out this form completely.
1) Photo Consent: We love staying connected with our patients on social media! Do we have your permission to
share your pet(s)’ image and story on social media, our website, our blog, and other forms of related media? Your
name and personal information will never be shared. Simply check below to authorize this:
Yes. I authorize CHAH to share my pet’s photo & story. No. I do not authorize this.
2) Treatment Consent: I hereby authorize the veterinarian(s) of Caring Hands Animal Hospital to examine, prescribe
for, and/or treat the above described pet(s). I assume responsibility for the charges incurred for the care
provided. I also understand that payment is due in full at the time of service. Deposits may be required in some
instances. For services requiring hospitalization, including boarding, fees are to be paid in full at discharge. In
the event of a returned check or non-payment, I agree to be responsible for the $35 collection fee, as well as a
1.5% service fee that will be added to the account in addition to the entire amount due.
* Name of Spouse/Additional Owner:
Spouse Phone:
Spouse Email:
Address if di!erent from Owners:
Primary Phone: Cell Phone: Work Phone:
Email: Emergency Contact:
Pet’s Name: Species: Dog Cat Other:
Breed: Color/Special Markings:
Date of Birth or Approximate Age: Sex: M / F Spayed or Neutered? Yes No Unsure
Previous animal hospital, if any:
Signature of Owner/Agent: Date:
Owner’s Name:
Street Address:
City: State: Zip:
Driver’s License #:
How did you find out about our practice?
(Check any that apply. If you were referred by a current client, tell us
so we can thank them!)
Referred by:
Drove By Google/Internet Search
Facebook Yelp
Phone Book Angie’s List
Visited our website Other:
Must be 18 years or older to sign.
* Note: The spouse/additional owner will have the rights to authorize medical care and changes to the account.
Which social media platforms do you use?
(Check any that apply.)
Facebook Twitter Pinterest
LinkedIn Instagram Vine
YouTube Google + Snapchat
click to sign
signature
click to edit
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